Healthcare Provider Details

I. General information

NPI: 1932193984
Provider Name (Legal Business Name): MARYCREST MANOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 12/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10664 SAINT JAMES DRIVE
CULVER CITY CA
90230
US

IV. Provider business mailing address

10664 SAINT JAMES DRIVE
CULVER CITY CA
90230
US

V. Phone/Fax

Practice location:
  • Phone: 310-838-2778
  • Fax: 310-838-9647
Mailing address:
  • Phone: 310-838-2778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number910000079
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: VERONICA MALDONADO
Title or Position: ADMINISTRATOR
Credential:
Phone: 310-838-2778